are achievable. Early progress toward the goal of more integrated, coordinated, and regionalized emergency and trauma care systems became derailed over the last two decades (see Chapter 2). Efforts stalled because of deeply entrenched interests and cultural attitudes, as well as funding cutbacks and practical impediments to change. These obstacles remain today and represent the primary challenges to achieving the committee’s vision. However, the problems are becoming more apparent, and this provides a catalyst for change. The committee calls for concerted, cooperative efforts at multiple levels of government and the private sector to finally break through and achieve these goals.

This chapter describes the committee’s vision for a 21st-century emergency and trauma care system. This vision rests on the broad goals of improved coordination, expanded regionalization, and increased transparency and accountability, each of which is discussed in turn. The chapter then profiles current approaches of states and local regions that exhibit these features. Finally, the chapter details the committee’s recommendation for a federal demonstration program to support additional state and local efforts aimed at attaining the vision of a more coordinated and effective emergency and trauma care system.


Today’s emergency and trauma care system suffers from fragmentation along a number of different dimensions. As described in Chapter 2, EMS occupies a space that overlaps three major silos: health care, public health, and public safety. In most cases, these three systems are not aligned, and their means of communicating or coordinating with one another are highly limited. Within health care, there is considerable fragmentation along a number of dimensions relating to EMS. For example, coordination among 9-1-1 dispatch, prehospital EMS, air medical providers, and hospital and trauma centers is often lacking (NHTSA, 1996). EMS personnel arriving at the scene of an incident often do not know what to expect regarding the number of injured or their condition (McGinnis, 2005). They also are frequently unaware of which hospitals are on diversion status and which are ready to receive the type of patient they are transporting. Lack of coordination between EMS and hospitals can result in delays that compromise care. In addition, deployment of air medical services is often not well coordinated. While air medical providers are not permitted to self-dispatch, a lack of coordination at the ground EMS and dispatch level sometimes results in multiple air ambulances arriving at the scene of a crash even when all are not needed. Similarly, police, fire, and EMS personnel and equipment often overcrowd a crash scene because of insufficient coordination regarding the appropriate response.

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